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TMSIS Dataguide Medicaid.gov
Version 3.38.0

RULE-1954

Validation Rule
Last updated

Tier 1.1
Tier Description Value Error
Error Category E1103
Error Category Message Value not in specified valid value set
Rule Type Valid Value
File Segment Number CRX00002
Data Element Name CLAIM-LINE-RECORD-RX.CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT
Validation Logic 'if CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY does not equal 'F2' and CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS is not equal to one of the following: '26', '87', '542', '585', '654', then If the field is populated, the value must be contained in the set of valid values with id: 'CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT' and (if CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE is non-null then CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE >= Valid Values Effective-Date and CLAIM-HEADER-RECORD-RX.PRESCRIPTION-FILL-DATE <= Valid Values End-Date)'
Rule Definition If the CMS 64 category for federal reimbursement is populated on a non-denied claim line from an RX file, then the CMS 64 category for federal reimbursement value reported must be in the list of valid values for CMS 64 category for federal reimbursement.
Denominator Logic # of RX claim lines with CLAIM-HEADER-RECORD-RX.CLAIM-STATUS-CATEGORY not equal to 'F2' AND with CLAIM-LINE-RECORD-RX.CLAIM-LINE-STATUS not in '26', '87', '542', '585', '654' AND with CLAIM-LINE-RECORD-RX.CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT equal to a valid, non-null value